MDS Alert

Question 1: Can you explain the difference between active diagnoses and diagnoses that cannot go on the MDS in Section I?

Answer 1: Active diagnoses are those diagnoses that have occurred in the seven days during the look back period, and those diagnoses that have a direct impact on the resident’s current status. This includes functional, cognitive, mood, and behavior status. It also considers treatments, nursing monitoring, or the risk of death. All physician documented diagnoses that were indicated and documented during the last 60 days must be considered. However, only those that impact the status, as identified above, during the previous seven days, would be the ones that would be indicated in Section I. The one exception is UTI, which has a look back period of 30 days. Just as a caution, any diagnosis must be documented by a physician or a physician extender.

Question 2: What is the definition of UTI? Currently anybody who is on an antibiotic after a urine culture or urinalysis is considered to be a UTI. I keep telling the staff that this is not correct but I need help in getting them to change their minds.

Answer 2: Chapter 3, Section I, Page 8 of the RAI manual defines a UTI in the following manner:

All of the following four criteria must be met

1. A physician or physician extender must have diagnosed a UTI within the last 30 days;

2. There must be documentation of signs or symptoms that may be contributed to a UTI;

3. There must be significant laboratory findings; and

4. The resident is on, or he has been on, medication or treatment for the UTI within the last 30 days.

Question 3: Can you give me an example of a non-medication intervention for pain?

Answer 3: A non-medication pain intervention is defined as an intervention that is scheduled and implemented but not related to medication at all. Biofeedback, massage, electrical stimulation, acupuncture and hot/cold packs, are a few examples. The RAI manual also includes physical therapy and stretching and strengthening exercises. However, be sure that these services are being rendered to alleviate pain.

Question 4: If a resident is on a pain management program, with scheduled pain medications, but also requires PRN medications for breakthrough pain, are both J0100 A and B coded?

Answer 4: Yes, since both are impacting the resident’s pain management, they would both be coded.